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LDL Cholesterol and Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation
Alexander Omelchenko1, Tzipi Hornik-Lurie2, Hagit Gabay3
1Cardiology Department, Meir Medical Center, Kfar Saba, Israel.
Insights
Low-density lipoprotein cholesterol (LDL-C) levels do not increase ischemic stroke risk in atrial fibrillation patients on direct oral anticoagulants (DOACs). This finding suggests dyslipidemia should not be used for stroke risk stratification in this population.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Atrial fibrillation increases ischemic stroke risk.
- The role of low-density lipoprotein cholesterol (LDL-C) in this risk is not well understood.
- This study investigates LDL-C and stroke risk in atrial fibrillation patients treated with direct oral anticoagulants (DOACs).
Purpose of the Study:
- To examine the association between LDL-C levels and incident ischemic stroke.
- To determine if LDL-C influences stroke risk in patients with atrial fibrillation on DOACs.
- To assess the utility of LDL-C in stroke risk stratification for this patient group.
Main Methods:
- Retrospective cohort study using electronic health records from Clalit Health Services, Israel.
- Included 21,229 patients with nonvalvular atrial fibrillation treated with DOACs (2010-2017).
- Patients stratified by CHA2DS2-VASc score and LDL-C levels (<70, 70-99, 100-130, >130 mg/dL); ischemic stroke rates compared.
Main Results:
- A total of 2481 ischemic strokes occurred during 56,467 person-years of follow-up.
- Higher CHA2DS2-VASc scores significantly correlated with increased ischemic stroke risk (P < .001).
- No association found between LDL-C levels and incident ischemic stroke within any CHA2DS2-VASc score group, even after multivariate adjustment.
Conclusions:
- LDL-C levels are not associated with ischemic stroke risk in atrial fibrillation patients treated with DOACs.
- Findings suggest dyslipidemia should not be included in ischemic stroke risk stratification for this population.
- This contrasts with findings in the general population.
Background:
Atrial fibrillation confers higher risk of ischemic stroke, but the contribution of low-density lipoprotein cholesterol (LDL-C) levels to this risk remains unclear. We examined the association between LDL-C levels and incident stroke in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs).
Methods:
This study was conducted using the electronic database of Clalit Health Services in Israel. Included were 21,229 patients with first-time diagnosis of nonvalvular atrial fibrillation treated with DOACs between 2010 and 2017. Patients were categorized into 4 groups according to the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], type 2 diabetes, previous stroke or transient ischemic attack [doubled], vascular disease, age 65-74 years, and sex category) score (1-2, 3-4, 5-6, 7-9). Each group was further stratified to 4 sub-groups according to LDL-C levels (<70, 70-99, 100-130, >130 mg/dL). Ischemic stroke rates were compared among the 4 LDL-C subgroups of each CHA2DS2-VASc category.
Results:
During 56,467 person-years of follow-up, there were 2481 incidents of ischemic stroke. Higher CHA2DS2-VASc score was associated with significantly increased risk of ischemic stroke (17.5, 26.9, 46.3, 94.9 cases per 1000 person-years, for patients with CHA2DS2-VASc score of 1-2, 3-4, 5-6, and 7-9, respectively; P < .001). However, there was no association between LDL-C levels and incident ischemic stroke within each CHA2DS2-VASc score group, even following a multivariate adjustment. Subanalyses of patients with previous stroke and those treated with statins also failed to show any association between LDL-C levels and incident ischemic stroke.
Conclusions:
Unlike the general population, LDL-C levels were not associated with ischemic stroke risk among patients with atrial fibrillation treated with DOACs. The findings support the noninclusion of dyslipidemia in ischemic stroke risk stratification of patients with atrial fibrillation.
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